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Multicomponent assessment and treatment of cigarette pica

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Multicomponent assessment and treatment of cigarette pica
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Goh, Han-Leong
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Cigarettes ( jstor )
Experimentation ( jstor )
Functional analysis ( jstor )
Helmets ( jstor )
Ingestion ( jstor )
Mental stimulation ( jstor )
Philosophical psychology ( jstor )
Pica ( jstor )
Social interaction ( jstor )
Toys ( jstor )
Dissertations, Academic -- Psychology -- UF ( lcsh )
Psychology thesis, Ph.D ( lcsh )
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bibliography ( marcgt )
non-fiction ( marcgt )

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Thesis:
Thesis (Ph.D.)--University of Florida, 1997.
Bibliography:
Includes bibliographical references (leaves 50-53).
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Typescript.
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Vita.
Statement of Responsibility:
by Han-Leong Goh.

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MULTICOMPONENT ASSESSMENT AND TREATMENT OF
CIGARETTE PICA















By

HAN-LEONG GOH


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF
THE UNIVERSITY OF FLORIDA
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE
DEGREE OF DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA






























Copyright 1997

by

Han-Leong Goh














ACKNOWLEDGEMENTS


I wish to express my gratitude to all who have helped make this study

possible. Thanks go to Dr. Brian A. Iwata, my committee chair and major

professor, for his invaluable assistance throughout the study and, more generally

throughout my years in graduate school, for his tireless endeavor in shaping my

professional and nonprofessional repertoire. Appreciation is also extended to

Drs. Marc Branch, Timothy Hackenberg, Alan Spector, and Stephen Golant for

serving on my committee.

I also acknowledge my fellow graduate students, SungWoo Kahng, Dorothea

Lerman, Bridget Shore, Sonya Fischer, Jana Lindberg, Michele Wallace, Iser

DeLeon, and Juliet Burke, who served as therapists and/or observers during

various times of the study. Special thanks go to Bridget Shore who provided

insightful comments regarding conceptual issues of the study.

Finally, I am deeply appreciative of the continual love, respect, and support
provided by my parents, Kong Chuan and Florence, and my brothers Han Lin

and Han Hsiung.















TABLE OF CONTENTS



ACKNOWLEDGEMENTS........................................................ ..................... iii

LIST O F TA BLES....................................... ................................................. v

L IST O F FIG U R E S....................................................................... ..................... vi

A B ST R A C T ............................................................. ........................... vii

IN TRO D UCTIO N ...................................... ................................................ 1

M E T H O D ................................................................................................................ 16

Participants and Setting........................ ......................... ...... 16
Experimental Design and Procedures...................... ................ 17
Stimulus Preference Assessments..................... .................... 18
Results and Discussion of Stimulus Preference
Assessm ents....................... .......... ....... ......................... 22
T reatm ent........................................... ................................................... 26

RESULTS AND DISCUSSION............................................. .................... 37

GENERAL DISCUSSION............................. .......................... 45

R EFE R E N C ES.............................................................................. .................... 50

BIOGRAPHICAL SKETCH............................................................ ... 54














LIST OF TABLES


Table page

1 Results of cigarette component preference assessment............ 23

2 Results of edible item or toy preference assessment................. 24

3 Results of cigarette component vs. edible item preference
assessm ent............... ......... ... ...................... 25

4 Interobserver agreement for cigarette pica and correct
exchange............................................ ... ................ ... 28














LIST OF FIGURES


Figure page

1 Latency to cigarette pica (seconds) and percentage of trials
of correct exchange (during training trials) for Rob,
Helen, and Andy.......................... .................... 39

2 Latency to cigarette pica (seconds) and percentage of trials
of correct exchange (during training trials) for Larry.......... 43









Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

MULTICOMPONENT ASSESSMENT AND TREATMENT OF
CIGARETTE PICA

By

Han-Leong Goh

December, 1997

Chairman: Brian A. Iwata, Ph.D.
Cochairman: Marc N. Branch, Ph.D.
Major Department: Psychology

Pica, a behavior disorder common among individuals with developmental

disabilities, is defined as the ingestion of nonedible substances. It is a form of

self-injurious behavior due to substantial health risks posed to those exhibiting

pica. One topography of pica involves the ingestion of cigarette products. Few

studies have focused on the treatment of cigarette pica, and attempts to identify

factors responsible for the maintenance of pica have been rare. Thus, the

purpose of the study was to demonstrate a methodology for the assessment and

treatment of cigarette pica.

Four individuals with developmental disabilities participated. Assessment

procedures were conducted in three distinct phases. First, preference for

cigarette components was assessed to identify the specific reinforcing component

of the cigarette. Second, preference for edible or leisure items was assessed to

identify possible potent alternative reinforcers that may be used during

treatment. Third, preference between cigarette and noncigarette stimuli was

assessed to determine if the alternative reinforcer could compete effectively with

cigarettes and, thus, may be used in reinforcement-based treatment procedures

to eliminate pica. Results indicated that stimulus preference assessments were
vii








successful in identifying the reinforcing component of the cigarette, and in

identifying alternative reinforcers, and suggested the feasibility of using

alternative reinforcers during treatment to eliminate cigarette pica.

The effectiveness of two treatment procedures was evaluated. Noncontingent

reinforcement with the alternative reinforcer was found to be effective at dense

schedules for two of the participants, but initial treatment effects failed to

maintain during schedule thinning. Differential reinforcement of an alternative

behavior with the alternative reinforcer was effective in deterring pica for three

participants. An evaluation of 10 treatment procedures failed to identify an
effective intervention for the remaining participant; consequently, preventive

measures were designed to minimize occurrences of cigarette pica. Noteworthy
contributions as well as limitations of the study are discussed, along with future

directions for research.














INTRODUCTION

Pica is defined as the ingestion of inedible substances (Gutelius, Millican,

Layman, Cohen, & Dublin, 1962). Although many topographies of pica have
been reported in the literature, all can be categorized as either (a)
nondiscriminant, in which individuals ingest a variety of objects such as strings,

rags, paper, leaves, grass, metal, glass, plastic, wood, toiletries, hair, nails, insects,

and paint; or (b) specific to certain classes of stimuli, such as ingestion of feces

(coprophagia); soil, floor dirt, sand, and rocks (geophagia); or cigarette products
(Danford & Huber, 1982). Danford and Huber (1982) conducted a survey over a
2-year period among a population of 991 institutionalized residents diagnosed

with mental retardation and found the prevalence of pica to be approximately

16.7%. Similar results were reported in a more recent survey in which the
prevalence of pica was found to be approximately 15.5% among a sample of 806
individuals (Lofts, Schroeder, & Maier, 1990). Thus, pica is a relatively common
behavior disorder, and the present study describes a multicomponent approach

to its assessment and treatment.

Pica poses two problems that warrant treatment. The primary concern is that
pica is considered a form of self-injurious behavior due to the potential for
physical harm such as lead poisoning (Finney, Russo, & Cataldo, 1982), intestinal
blockage (Albin, 1977), and parasitic infestation (Foxx & Martin, 1975). A
secondary concern is that ingestion of inedible substances is not considered

socially appropriate; this is especially true for certain topographies of pica,
namely coprophagia, which involves ingestion of bodily wastes. Furthermore,
socially offensive response products may be evident, such as odor and the









presence of feces around the mouth, fingernails, and other parts of the body
(Foxx & Martin, 1975). Thus, pica can be an inherently dangerous behavior and,

if not, may nevertheless pose a barrier to social integration.
One theory concerning etiology suggests that individuals who engage in pica
are nutritionally deficient (Danford, Smith, Jr., & Huber, 1982). Studies have
found that individuals who engaged in pica also were deficient in specific
minerals such as iron (Crosby, 1971; Moore & Sears, 1994), zinc, copper,
magnesium, (Cavdar & Arcasoy, 1972), and vitamin B components (Bugle &
Rubin, 1993). Most of these studies did not conduct experimental manipulations
to determine if nutritional deficiency was the cause of or an effect of pica. Two
notable exceptions were the Bugle and Rubin (1993) and Gutelius et al. (1962)
studies. Bugle and Rubin (1993) found that increasing the supplemental intake of
vitamin B components resulted in a decreased level of pica, providing some
support for the hypothesis that nutritional deficiency was the basis for pica. On
the other hand, Gutelius et al. (1962) found that although individuals with pica
were iron-deficient, the behavior was equally suppressed among two groups of
individuals: those who received saline injections, and those who received
injections with iron supplements. Thus, because differential improvement was
not evident in the two groups, the findings did not support the theory of
nutritional deficiency as the etiological basis for pica; instead, it is possible that
other factors were responsible for behavioral maintenance and that nutritional
deficiency was a result of pica.
Danford, Smith, Jr., and Huber (1982) hypothesized that nutritional deficiency
was not the etiological basis for pica but, instead, occurred as a result of the
behavior. That is, ingestion of certain objects may cause a chemical reaction (i.e.,
binding effect) or chelation with certain minerals that may result in deficiency of
those minerals. In other words, they posited that nutritional deficiency may not









be a feasible etiological account of pica and that the cause of pica remains to be

identified. They analyzed blood, plasma, and hair samples for a group of 60

individuals who engaged in pica versus a control group of 60 individuals who

did not engage in the behavior and measured concentration levels of minerals

such as iron, zinc, copper, and magnesium in both groups. Their findings

indicated that plasma iron and zinc concentrations were markedly lower in

individuals who engaged in pica relative to those who did not. However,

because no experimental manipulations were conducted, their results only

suggested a correlation between individuals who engage in pica and low

concentrations of certain minerals. As they stated, a definitive illustration that

mineral deficiency is caused by pica has yet to be made. Nevertheless, given

mixed findings from the Gutelius et al. (1962) and Bugle and Rubin (1993)

studies, and lack of further supporting evidence, it appears that the theory of

nutritional deficiency as a possible etiological basis for pica is not well

substantiated.

A second theory that has not received much attention in the literature is the

possibility that pica may be maintained by social consequences. Given the

potential for physical harm as a result of pica, it would seem that immediate

attention (e.g., reprimands, attempts to remove ingested objects, or

implementation of emergency medical procedures) would often be delivered as a

consequence to certain forms of pica. Alternatively, pica may be a highly

effective escape response during instructional activity if it terminates the task at
hand. Thus, pica may serve as either an attention-seeking response or as an

escape response. To date, however, no studies have provided evidence

indicating that pica is maintained by social consequences.

A common feature of the two theories is that pica is viewed as learned
behavior maintained by consequences. The theory of nutritional deficiency is a









biological theory suggesting that pica is maintained by specific stimulus
characteristics that are directly produced by ingestion of inedible objects (i.e., it
does not involve mediation through the action of others). That is, the behavior
seems to produce its own reinforcing consequences; hence the term "automatic
reinforcement" (Vaughan & Michael, 1982) would seem to apply when
describing the general class of reinforcement contingencies that maintain pica.
By contrast, the second theory emphasizes behavioral maintenance as a function
of social reinforcement. Thus, theories on pica can be differentiated on the basis
of automatic versus social reinforcement as the general class of maintaining
contingency.
Because no published research has investigated social reinforcement as the
etiological basis of pica, the emphasis has solely been on the automatically
reinforced nature of the behavior. One implication of these studies (Bugle &
Rubin, 1993; Cavdar & Arcasoy, 1972; Crosby, 1971; Moore & Sears, 1994) is that
individuals who engage in pica have learned to ingest specific inedible
substances (i.e., they were able to discriminate among types of inedible objects)

in order to obtain needed nutrients or to restrict the intake of those nutrients
(Danford, Smith, Jr., & Huber, 1982). Hence, it is possible that the basis for
learned discrimination may be specific reinforcing consequences produced from
ingesting particular stimuli. For example, an individual may ingest only clay
because it provides gustatory reinforcement. Thus, given the assumption that

pica is automatically reinforced, it may be possible to systematically identify the
specific reinforcer of the behavior. Only two studies (Favell, McGimsey, &
Schell, 1982; Mace & Knight, 1986) have attempted such an investigation.
Favell et al. (1982) evaluated the effectiveness of continuous access to
alternative sources of reinforcement in a series of 3 experiments for six
individuals with developmental disabilities who exhibited various topographies









of SIB, three of whom engaged exclusively in pica. In one experiment, the 3
participants were allowed free access to toys, popcorn, or both toys and popcorn,

to determine if alternative sources of reinforcement would effectively compete
with pica, which was defined as ingestion of clothing and small pieces of inedible
objects. Results showed that pica was equally suppressed compared to baseline,
in which alternative sources of reinforcement were unavailable, when either toys
or popcorn were freely available. Additionally the concurrent availability of
both toys and popcorn did not result in differential effectiveness when compared
to either one presented alone. The authors also observed an inverse relationship
between the level of toy chewing and that of pica, indicating that the
replacement behavior (toy chewing) effectively substituted for the target
behavior. Thus, the results suggested that (a) the replacement topographies for
pica (i.e., toy chewing and ingestion of popcorn) may suggest that oral
stimulation or gustatory reinforcement were the specific maintaining reinforcers,
and (b) providing continuous access to alternative sources of reinforcement may
be an effective treatment for pica. However, as the authors noted, conclusions
regarding the behavior's maintaining reinforcer were preliminary because the
assessment methodology used was an indirect one. That is, the methodology
involved continuous access to alternative sources of reinforcement, and
conclusions were based on the extent to which replacement topographies
competed with pica (i.e., the maintaining reinforcer was inferred based on the
extent to which near elimination of pica was observed concurrently with high
levels of toy chewing and ingestion of popcorn). A direct means of identifying
the maintaining reinforcer, which was not conducted in the study, would be to
modify some stimulus characteristics of the pica objects to see if such
manipulations would alter the frequency of pica.







6

Mace and Knight (1986) analyzed the relationships between environmental
variables and pica. The participant's (Jim) pica was defined as ingestion of

clothing and other materials that could be ripped or shredded and wedged
between his face and the shield of a helmet, which was worn to minimize

occurrences of the target behavior. Prior to conducting a functional analysis of

environmental variables purported to influence pica, a baseline condition was
designed. The purpose of the baseline condition was to provide a basis from
which to select specific environmental variables that would be systematically

manipulated during the functional analysis. The procedures during the baseline

condition were those that were occurring naturally in the classroom. That is, the

teacher provided Jim with instructions to engage in a task; once initial
instructions were delivered, the teacher provided attention intermittently (i.e., on
a variable time or VT 8 min schedule, in which time-based delivery of attention
occurred on the average of every 8 minutes) to all students in the classroom.

Contingent on pica, the teacher delivered mild reprimands while removing

objects from Jim's mouth.
The functional analysis was conducted in two phases. Phase 1 was designed
to determine the effects of noncontingent social interaction on pica. Throughout
all three conditions of Phase 1, Jim wore the helmet with the face shield. In two

conditions, social interaction was delivered independent of the occurrence of
pica on time-based schedules that ranged from VT 15 s (frequent-interaction
condition) to once every 3 minutes (limited-interaction condition), whereas no
social interaction was provided in the no-interaction condition. Phase 2 was
designed to examine the effectiveness of varying levels of protective equipment

on pica. Procedures during all three conditions were similar to those of the

limited interaction phase, with the exception that each condition differed with
respect to the level of protective equipment used. During the helmet with face









shield condition, a helmet identical to the one worn during Phase 1 was used;
during the helmet without face shield condition, a similar helmet was worn
without the face shield; and, during the no helmet condition, no protective
equipment was worn.
Results of the analyses of the social interaction and protective equipment
conditions indicated that, compared to baseline, the greatest level of response
suppression was evident in the frequent interaction and no helmet conditions.
Based on these results, Mace and Knight (1986) sought to identify whether the
two conditions (frequent interaction and no helmet) were functionally related to
each other in suppressing pica. They hypothesized that due to the lack of
protective equipment (no helmet condition), staff needed to closely supervise
and protect Jim from engaging in pica and, as a result of close staff supervision,
reprimands were delivered for a high proportion of pica responses (i.e.,
reprimands may have served as punishment)(frequent interaction condition).
Data relevant to this hypothesis were collected under naturalistic conditions.

The results indicated that staff interacted more often with Jim, and that pica-
contingent reprimands were higher when the helmet was not worn than when it
was worn, suggesting that Jim was able to discriminate situations in which he
could and could not engage in pica (i.e., the absence of the helmet with the face
shield likely was correlated with higher probabilities of punishment such that a
relatively lower level of pica occurred under that condition). Thus, the study

illustrated the use of a functional analysis to identify environmental stimuli that
were reliably correlated with different levels of pica. However, due to the
possibility that social interaction could have served a punishment effect, the
study did not identify the specific maintaining reinforcer of pica. Nevertheless,
the methodology used by Mace and Knight did rule out one potential source of
reinforcement: The highest level of pica was observed during the no interaction









condition, indicating that the behavior was probably not maintained by social

reinforcement. To identify the maintaining reinforcer, the authors could have

either systematically examined the effects of a variety of alternative sources of

reinforcement (e.g., toys or edible items) on pica, or directly manipulated
stimulus characteristics of the pica stimuli. The latter, direct analysis could be
conducted using the methodology proposed by Mace and Knight (1986) simply

by holding constant the amount of social interaction and level of protective

equipment used, while systematically manipulating stimulus characteristics of
the pica stimuli in an attempt to identify the behavior's specific maintaining
reinforcer.

Although the Favell et al. (1982) and Mace and Knight (1986) studies

illustrated preliminary methodologies for assessing the reinforcing effects of
pica, most research has focused largely on treatment evaluation. Effective

elimination or near elimination of pica has been found with the use of mineral
supplements (Bugle & Rubin, 1993; Gutelius et al., 1962); continuous free access
to alternative sources of reinforcement (Favell et al., 1982; Mace & Knight, 1986);

differential reinforcement of alternative behavior (DRA) (Johnson, Hunt, &

Siebert, 1994); a variety of punishment procedures such as physical restraint
(Singh & Bakker, 1984), timeout (Ausman, Ball & Alexander, 1974),
overcorrection (Duker & Nielen, 1993; Mulick, Barbour, Schroeder, & Rojahn,
1980), water mist and aromatic ammonia (Rojahn, McGonigle, Curcio, & Dixon,

1987), and lemon juice and water mist (Paisey & Whitney, 1989); drug therapy

(Stewart, 1995); and a combination of procedures including DRA, differential
reinforcement of other behavior (DRO), and overcorrection (Finney et al., 1982),
and DRA, DRO, timeout, and overcorrection (Kalfus, Fisher-Gross, Marvullo, &
Nau, 1987). In this sample of studies, only four (Bugle & Rubin, 1983; Favell et
al., 1982; Gutelius et al., 1962; Mace & Knight, 1986) have focused on aspects of







9

etiology. This emphasis primarily on treatment is also characteristic of research

on selective or discriminant forms of pica. The focus of this study will be on one
such form, namely, cigarette pica.

Cigarette pica typically involves ingestion of cigarette products to the
exclusion of others. In Danford and Huber's (1982) prevalence survey, cigarette

pica occurred in approximately 9% of the sample. There are three risk factors
associated with cigarette pica. First, chronic ingestion of tobacco may result in

oral cancer, gingival recession, and periodontal diseases (Piazza, Hanley, &

Fisher, 1996). Second, and of more immediate concern, is exposure to saliva-

borne pathogens that may spread communicable diseases, as well as exposure to
incidental pathogens (i.e., substances that comes into contact with cigarettes
laying on the ground). Third, intestinal blockage may occur as a result of
ingestion of large amounts of cigarettes.

There has been a dearth of research focusing on the assessment and treatment

of cigarette pica; and, of the four published studies to date (Donnelly & Olczak,
1990; Foxx & Martin, 1975; Matson, Stephens, & Smith, 1978; Piazza et al., 1996),

only one (i.e., Piazza et al., 1996) has attempted to identify the behavior's
maintaining reinforcer prior to treatment implementation. Foxx and Martin

(1975) evaluated the effects of overcorrection as a treatment for the pica of three

participants, one of whom exhibited cigarette pica. An A-B (baseline-treatment)
design with two one-session baseline reversal probes was used in the study.
During baseline, a cigarette butt was placed in an ashtray every 15 minutes, and
was replaced if taken, during an 8-hour period each day. During treatment,

similar procedures were in effect as in baseline. However, contingent on each

occurrence of cigarette pica, the participant engaged in an overcorrection
activity, which consisted of oral hygiene training (toothbrushing for 10 minutes),
personal hygiene training (handwashing for 10 min), and cleaning ashtrays (10









min). Physical prompting was used to ensure that the participant repeatedly
engaged in the required responses of each component of the overcorrection

procedure. Results showed that cigarette pica decreased and eventually was
eliminated during treatment, whereas responding was elevated during the two,

one-session reversals to baseline in which the overcorrection procedure was

removed.

Matson et al. (1978) also evaluated the effectiveness of an overcorrection
procedure on one participant who exhibited multiple topographies of SIB
(hairpulling and cigarette pica). A multiple-baseline design across target

behaviors was used. During treatment, the participant engaged in an

overcorrecton procedure contingent on each occurrence of cigarette pica, which

consisted of oral hygiene training (toothbrushing for 1 minute) and sweeping the
floor, emptying trash cans, and cleaning the floor of debris (9 minutes). Thus,
procedures used in the study were similar to those used by Foxx and Martin

(1975), except that the duration of overcorrection was shorter, and the personal
hygiene component was omitted. Results obtained were also similar to and

supported those reported by Foxx and Martin (1975) in that overcorrection was
effective in decreasing both target behaviors.
Donnelly and Olczak (1990) examined the effectiveness of a DRA procedure

on ingestion of placebo pica stimuli. Due to potential risks involved in using

actual cigarettes throughout the course of the study, the authors decided to use

placebo stimuli that shared certain stimulus properties of cigarettes but were safe
for consumption. The placebo stimuli were manufactured simply by removing a
2-3 cm portion from the crust of a slice of white bread, along with a 1 cm layer of
bread (Donnelly & Olczak, 1994). The bread was then rolled and compressed

into a cylinder approximately 1 cm in diameter, flattened, and one end singed

with a lighter. The appearance of the final product resembled that of a cigarette









butt. The DRA procedure consisted of reinforcing an alternative response (gum
chewing) with coffee and was shown to be effective. However, the major
limitation of the study was that the dependent variable was not cigarette pica
(i.e., no cigarettes were consumed at any time during the study). Hence, it
cannot be assumed that the DRA procedure would produce similar effects on
cigarette pica because it is unclear if the programmed reinforcer (coffee) could
have competed with pica in the presence of actual cigarette products.
Piazza et al. (1996) conducted a case study on the assessment and treatment of
cigarette pica for one participant, which included an attempt to identify factors
responsible for behavioral maintenance. The study consisted of three assessment
and two treatment phases. Phase 1 of the study was conducted to assess the
effects of tobacco on cigarette butt ingestion and consisted of two conditions. In
each condition, eight unsmoked cigarette butts containing the filter and 0.6 cm of
either herbs (herbal butts condition) or tobacco (tobacco butts condition) were
distributed throughout the session room and were freely available to the
participant. Results showed that the rate of ingestion was higher in the tobacco
butts condition than in the herbal butts condition, suggesting that tobacco was an
important determinant of cigarette pica.
Phase 2 of the study was designed to identify preferred components of
tobacco butts. A choice assessment (Fisher et al., 1992) was conducted in which
an unsmoked tobacco butt (0.6 cm of tobacco plus filter), an unsmoked herbal

butt (0.6 cm of herbs plus filter), tobacco (0.6 cm of tobacco removed from the
cigarette butt), herbs (0.6 cm of herbs removed from the cigarette butt), and
cigarette paper (0.6 cm of cigarette paper without tobacco or herbs) were
presented to the participant in pairs. The participant was only allowed to select
one of the two available stimuli per trial. Each stimulus was presented three
times with every other stimulus in a random order, yielding a total of 30 paired







12

presentations. Results indicated that tobacco was the stimulus that was selected

on most trials, suggesting that it was the specific reinforcer responsible for
behavioral maintenance.

Phase 3 involved the use of a functional analysis, the procedures of which

were similar to those first described by Iwata, Dorsey, Slifer, Bauman, and

Richman (1982/1994). In that study, four experimental conditions were designed
to assess functional relationships between self-injurious behavior (SIB) and
specific reinforcement contingencies among nine participants with

developmental disabilities. The social disapproval condition investigated the

possibility that SIB was maintained by contingent attention. At the outset of the
session, the experimenter directed the individual to play with toys and then
engaged in a work activity that necessitated minimal interaction with the
individual. Statements of concern and disapproval were provided contingent on

SIB, and an increased rate of SIB during this condition would suggest that

responding was maintained by attention. During the demand condition, the

experimenter presented a series of tasks to the individual and, contingent upon
SIB, briefly terminated the instructional sequence. An increased rate of
responding during this condition would suggest that SIB was maintained by

negative reinforcement in the form of escape from tasks. During the alone
condition, the individual was placed in a room devoid of any materials that
might serve as external sources of reinforcement; in effect, the situation
simulated a barren environment. An increased rate of responding during this
condition would suggest that SIB was maintained by automatic reinforcement.

During the unstructured play condition, no demands were placed on the

participant, toys were freely available, and attention was provided on an FT 30 s

schedule. This condition served as a control because the delivery of reinforcers
on either a continuous (toys, and escape from tasks) or FT (attention) basis would









ensure that functional relationships between the target response and
reinforcement contingencies would not be established. In the Piazza et al. (1996)

study, there were two procedural differences during the functional analysis.
First, the demand condition was not conducted. Second, in order to provide the

opportunity for cigarette pica to occur, cigarette butts were available throughout

the other conditions. Results indicated that responding was highest during the
alone condition and was at or near zero during the social disapproval and
unstructured play conditions, suggesting that cigarette pica was maintained by
automatic reinforcement.

Treatment evaluation was conducted in Phases 4 and 5. In Phase 4, the

authors compared the effectiveness of noncontingent food (NCF) condition with
or without response interruption (Interruption). During baseline, tobacco butts
and play materials were available, and no social interaction was provided as the

participant was alone in the room. During the NCF condition, preferred edible
items were made freely available throughout the session, and no consequences

were delivered by the experimenter following occurrences of cigarette pica.

During the NCF plus Interruption condition, preferred edible items again were
made freely available, and verbal reprimands accompanied by response

interruption was delivered contingent on tobacco butt pick-ups (i.e., attempts at
cigarette pica) and cigarette pica. Results indicated that rates of butt pick-ups

and cigarette pica were elevated in baseline and in the NCF condition. Cigarette

pica was completely suppressed in the NCF plus Interruption condition, whereas
the rate of butt pick-ups was suppressed markedly compared to baseline and the
NCF condition, although not completely eliminated. These results suggested
that NCF plus Interruption was effective, but that if left unsupervised, the

participant likely would engage in cigarette pica. During Phase 5, the authors

conducted a stimulus control procedure (i.e., using a specific color card with









which to associate procedures of the NCR plus Interrupt condition) to program

and assess generalization of treatment effects. Results suggested that the

treatment effects generalized in the absence of staff supervision in a variety of

settings.

The major contribution of the Piazza et al. (1996) study is the use of a
multicomponent assessment to identify the general reinforcement contingency

(automatic reinforcement) and the specific reinforcer (tobacco) maintaining

cigarette pica. A second contribution is that, based on results of assessment, a

nonintrusive treatment was designed and found to be effective under

experimental conditions, which generalized under naturalistic conditions.
However, in addition to these notable contributions, there are three limitations.

First, because only one individual participated in the study, the extent to which

similar effects would be observed across more participants is unclear. Second,

smoked tobacco butts, which likely would be the more common stimulus
ingested by those who engage in cigarette pica, were not included in the
preference assessment with cigarette components. Third, the schedule of food

delivery during both NCF conditions was unspecified; if a dense schedule of

noncontingent food was used, this may render the procedure impractical under

naturalistic conditions (i.e., it is unknown if treatment effects would maintain
under leaner schedules).

Thus, of the four studies focusing on cigarette pica, the Donnelly & Olczak

(1990) study provided no treatment data on actual cigarette pica. In the

remaining three studies, a total of three participants received treatment, only one
of whom underwent an assessment to identify the maintaining reinforcer for

pica. Thus, the purpose of this study was to conduct a more thorough evaluation
of the role of behavioral assessment in developing treatment for cigarette pica,







15

and to demonstrate treatment effects with actual cigarette pica across several

individuals to evaluate generality of intervention.














METHOD

Participants and Setting

Four individuals participated. All participants lived in a state residential

facility for persons with developmental disabilities and were referred to a day

treatment program for the assessment and treatment of their cigarette pica. Rob,

a 40-year-old male, was diagnosed with profound mental retardation, was

ambulatory, occasionally responded to one- or two-word requests, displayed no

expressive language, and was not receiving any psychotropic medications

during the course of the experiment. Helen, a 49-year-old female, was diagnosed

with severe mental retardation, was ambulatory, complied with multiple

requests, displayed echolalia but also could use functional words in a sentence

within a limited context (e.g., "Can I have coffee?"), and was receiving 25mg of

Mellaril BID. Andy, a 44-year-old male, was diagnosed with profound mental

retardation, was ambulatory, responded frequently to one- or two-word

requests, displayed no expressive language, and was receiving 50mg Mellaril

BID as well as a prescribed medication to control seizures. Larry, a 46-year-old

male, was diagnosed with profound mental retardation, was ambulatory, was

visually impaired, responded occasionally to one- or two-word requests, and

was receiving 100mg Mellaril BID.

All sessions were conducted either in therapy rooms located at the day
program, or outside on the grounds immediately adjacent to either the day

program or the participants' residences or worksites. Session times varied in

length depending on the condition implemented, and two to eight sessions were

conducted per day, at least four days per week. Also present in each room were

16









a table and at least one chair, as well as materials specific to various conditions of

the experiment.

Experimental Design and Procedures
A pretreatment functional analysis (Iwata et al. 1982/1994) to identify
functional relationships between environmental stimuli and cigarette pica was
not conducted based on staff reports and informal observations during the

admission screening process that all participants were observed to engage in

cigarette pica when alone or unsupervised. Thus, it appeared unlikely that

cigarette pica was maintained by social reinforcement. In essence, the
underlying assumption made during the course of the experiment was that
cigarette pica was maintained by direct access to cigarette products.

Thus, the experiment was designed to identify the specific reinforcer

responsible for behavioral maintenance and to evaluate treatment effectiveness
on pica in three phases. Phase 1 consisted of three stimulus preference

assessments, which were designed to determine preference for cigarette
components, edible items or leisure materials (toys), and preferred cigarette

components or preferred edible items. Phase 2 consisted of an evaluation of two

treatment procedures, noncontingent reinforcement (NCR) and DRA. Baseline

and treatment conditions were conducted in a multiple baseline design (Baer,
Wolf, & Risley, 1968) for Rob, Helen, and Andy. A reversal design was used for
Larry. Phase 3 consisted of programming and assessing the extent to which

treatment effects generalized under naturalistic conditions. In order to ensure

that the participants would not be placed at significant risk, the medical staff of
the residential facility determined that a maximum of two whole cigarettes could
be ingested per day during sessions at the day treatment program.









Stimulus Preference Assessments
There were three purposes for assessing preference. First, given the

assumption that cigarette pica was maintained by automatic reinforcement, a

related assumption was that some stimulus characteristic of the cigarette was the

specific maintaining reinforcer. That being the case, one purpose was to identify

the reinforcing component of the cigarette. The second purpose was to identify
potential alternative stimuli that might be used during treatment to compete

with the target behavior. The third purpose was to determine if a preferred

alternative stimulus would actually compete with the reinforcing component of

the cigarette when both were concurrently available. If so, delivery of the
alternative stimulus on either a noncontingent or contingent basis might
suppress pica. Three separate preference assessments were conducted in a
sequential fashion to determine, respectively, preference for: (a) cigarette

components; (b) edible items or toys; and (b) preferred cigarette components or

preferred edible items.
Interobserver Agreement for Stimulus Preference Assessments
Interobserver agreement was assessed for a proportion of the data by having
a second observer simultaneously but independently collect data with the

primary observer. An agreement was defined as both observers having scored

the same selection or no selection in the same trial. Percentage agreement on
item selection was calculated by dividing the number of trials containing scoring
agreements by the total number of trials in the session. During the cigarette
component preference assessment, agreement was assessed during 1 of 3 (33.3%)

of Helen's sessions with an agreement score of 100%. During the edible items or

toys preference assessment, agreement was assessed for 2 of 5 (40%) of sessions

for each participant. Agreement scores for Helen, Andy and Larry were always
100%; the mean agreement score for Rob was 97.6% (range of 95.2% to 100%).









During the preferred cigarette component versus preferred edible item
preference assessment, agreement was assessed during 1 of 2 (50%) sessions for
both Andy and Larry, and scores never deviated from 100%.
Cigarette Component Preference Assessment
During this condition, preference for three cigarette (Marlboro Lights 100's)
components was assessed: an unsmoked filter, an unsmoked cigarette, and a
smoked cigarette butt. The unsmoked filter contained only the filter portion of
the cigarette (approximately 3 cm in length) devoid of tobacco. Each unsmoked
filter was divided into equal portions, each approximately 1 cm in length
(henceforth, the term "unsmoked filter" will be used to refer to each 1 cm

unsmoked filter component of the cigarette). The unsmoked cigarette

(approximately 6.5 cm in length) contained the tobacco-portion of the cigarette
encased in paper minus the filter. Each unsmoked cigarette was divided into 5
equal portions, each approximately 1.3 cm in length (henceforth, the term
"unsmoked cigarette" will be used to refer to the 1.3 cm portion of tobacco

encased in paper). To ensure that smoked cigarette butts were free of saliva-
borne and incidental pathogens, cigarette butts were manufactured in the
following manner. A needleless syringe (10 ml or 20 ml capacity) was inserted
into the filter portion of an ignited cigarette, and cigarette smoke containing
combusted tobacco (nicotine) was drawn through the filter by the action of the
upward and downward motion of the plunger of the syringe. The resulting
"smoked" cigarette butt measured approximately 1.2 cm after the manufacturing

process and was divided into three equal portions of approximately 0.4 cm
(henceforth, the term "cigarette butt" will be used to refer to each 0.4 cm syringe-
smoked portion of the cigarette). In order to comply with the limit of 2 whole
cigarettes consumed per day, sessions were terminated following the ingestion of









an amount of a cigarette component that was equivalent to 2 whole cigarettes

(i.e., 6 unsmoked filters, 10 unsmoked cigarettes, or 6 cigarette butts).

Preference for cigarette components was assessed in a paired presentation
format described by Fisher et al. (1992) in which the participant was allowed

access only to one of two concurrently available cigarette components. Each
cigarette component was presented six times with the other two cigarette

components in a random order, yielding a total of 18 paired presentations (one

paired presentation per trial). A session consisted of six trials, and between one

and two sessions were conducted per day, depending on when the limit of
cigarette ingestion was attained. Thus, the cigarette component assessment was
completed within three days. Prior to the beginning of the first session,

participants were given a sample of each cigarette component. For each trial,

two different cigarette components were placed approximately 30 cm apart from

each other and 20 cm in front of the participant. An approach response to a
cigarette component resulted in access to that stimulus and removal of the
unselected cigarette component. If no approach responses occurred within 5 s,

the experimenter prompted the participant to sample (i.e., pick up and ingest)

each stimulus, then the same two stimuli were replaced in front of the participant

for 5 s. If approach responses then occurred, they resulted in access to the
selected stimulus and removal of the unselected stimulus, whereas no
approaches resulted in removal of both stimuli and initiation of the next trial.

Edible Item or Toy Preference Assessment

The purpose of this assessment was to identify participants' preference for
food/drink items or toys. The assessment was conducted using a multiple-

stimulus format described by DeLeon and Iwata (1996) for Helen, Andy, and
Larry. A paired presentation format similar to the one described during the
cigarette component preference assessment was used for Rob except seven items









were assessed, and each stimulus was paired once with every other stimulus,

yielding a total of 21 paired presentations. Five sessions were conducted for all

participants. Prior to the beginning of the first session, participants were given a

sample of each item. Each session began with an array of items (n = 7) sequenced

randomly along a straight line on a table, approximately 5 cm apart. While a

participant was seated approximately 0.3 m from the stimuli, the experimenter

instructed the participant to select one item. After an item was selected, it was

not replaced. Prior to the next trial, the sequence of the remaining items was

rotated by taking the item on the left end of the line and moving it to the right

end, then shifting the items to ensure again that they were equally spaced apart.

The second trial then began immediately. This procedure continued until all

items were selected or until no selection was made within 30 s from the

beginning of a trial.

Preferred Cigarette Component Versus Preferred Edible Item/Toy Preference
Assessment

Based on results of the previous phases, a third assessment was conducted to

determine preference between the cigarette component and edible item or toy

(alternative stimulus) that were most frequently selected in previous preference

assessments. Preference for the alternative stimulus over cigarettes may suggest

that use of the alternative stimulus during treatment may be effective in

competing with the target behavior. The procedures used during this phase

were similar to those of Phase 1, except that only two stimuli (a cigarette

component and an alternative stimulus) were used. The number of paired

presentations ranged from 20 (Helen, Andy, and Larry) to 30 (Rob). In addition,

preference between unsmoked cigarettes coated with a distasteful substance

(Scorned Woman Hot Sauce@, henceforth called "spiked" cigarettes) and the









most preferred food item was assessed for Larry using similar procedures just

described across 30 trials.
Results and Discussion of Stimulus Preference Assessments

Table 1 shows the results of the cigarette component preference assessment.

Rob, Helen, and Larry selected the unsmoked cigarette most often (100% of trials

for Rob and Helen, and 91.7% for Larry). Preference was not as marked for

Andy, although he selected the cigarette butt (66.7%) more often than he selected
either the unsmoked filter (50.0%) or the unsmoked cigarette (33.3%). Thus, the
results indicated that Rob, Helen, and Larry preferred unsmoked cigarettes,
whereas Andy preferred cigarette butts.

Table 2 shows the results of the edible item and toy preference assessment.

During the assessment, Rob selected M & M candy during 100% of trials during

which it was available, which represented a slight preference relative to the
cookie (83.3%) and more so relative to the remaining items. Helen selected coffee

100% of trials during which it was available, which represented a marked

preference over the remaining items. By contrast, Andy showed only a slight

preference for sliced beets (45.5%) over plain crackers (41.7%) and Larry showed

a slight preference for Kit Kat@ candy (45.5%) over pudding (41.7%). Thus, the
preference assessment identified an edible item as preferred relative to other
edible items and toys, but the absolute level of preference was highest only for

Rob and Helen and moderate for Andy and Larry.

Table 3 shows the results of the preferred cigarette component versus the
preferred edible item preference assessment. Rob selected the edible item on
83.3% of trials and he selected the cigarette component on 16.7% of trials, Helen
selected the edible item on 80.0% of trials and she selected the cigarette

component on 20.0% of trials, and Andy selected the edible item on 95.0% of
trials and selected the cigarette component on 5.0% of trials. By contrast, Larry







23

Table 1 Results of Cigarette Component Preference Assessment





Participant % Trials Selected

Unsmoked Unsmoked Cigarette
Filter Cigarette Butt

Rob 0 100 33.3
Helen 0 100 50.0
Andy 50.0 33.3 66.7
Larry 0 91.7 58.3








24

Table 2 Results of Edible Item or Toy Preference Assessment





% Trials Selected

Item Rob Helen Andy ay

M&M 100 -- 33.3
Cookie 83.3 -- --
Pretzel 56.7 -- 21.7 22.7
Coffee 46.7 100 -- 11.4
Sliced Beets 43.3 14.7 45.5 --
Vibrator 13.3 -- --
Koosh Ball@ 6.7 -- 12.5 -
Diet Coke@ 41.7 -- 31.3
Cheese
Cracker -- 31.3 --
Pudding -- 25.0 -- 41.7
Spree@ -- 21.7 -
Jello -- 16.7 --
Plain Cracker -- 41.7
Juice -- 35.7
Bead Necklace 8.8 --
PB & Cheese
Cracker -- 25.0
Kit Kat@ -- -- 45.5
Skittles -- -- 20.8







25
Table 3 Results of Cigarette Component vs. Edible Item
Preference Assessment


% Trials Selected


% Trials Selected


Preferred Preferred "Spiked" Preferred
Cigarette Edible Cigarette Edible
Component Item Item


Rob
Helen
Andy
Larry


Participant









selected the cigarette component on 95.0% of trials and selected the edible item

on 5.0% of trials. Thus, 3 of the 4 participants showed marked preference for the

preferred edible item versus the preferred cigarette component. Because Larry
selected the preferred cigarette component more often than he selected the

preferred edible item, another assessment was conducted to see if stimulus
characteristics of the cigarette component could be altered such that the edible

item may be preferred; this was the basis for assessing preference between

spiked cigarettes and the preferred edible item. Results indicated that Larry
selected the edible item on 63.3% of trials and selected the spiked cigarette on
36.7% of trials. Although the difference in preference between the preferred
edible item and spiked cigarette was smaller than that observed between the
preferred edible item and unaltered cigarette component for the other

participants, Larry's data suggested that the edible item may compete with
spiked cigarettes.

Treatment
Response Measurement and Interobserver Agreement

Cigarette pica was defined as placement of a cigarette product into the mouth

past the plane of the upper and lower lips. Due to the restriction on the number
of cigarette products that could be ingested, a measure of cigarette pica based on
frequency would not accurately reflect participants' free operant rate of
responding. Thus, latency to the first response was used as the dependent

measure of cigarette pica throughout the study. Data were also collected on two
additional participant responses, ingestion of food and independent exchanges

of cigarettes for food (correct exchanges), as well as on three experimenter
responses: delivery of food or the aversive stimulus, physical prompts, and

response interruption. Frequency of experimenter and participant behaviors,

with the exception of cigarette pica, was recorded on a hand-held computer









(Assistant, Model AST 102) during continuous 10 s intervals. A counter was
used to record the total number of trials elapsed during the DRA training phase.
Frequency of correct exchanges was converted to percentage of trials during
which responding occurred, and was calculated by dividing the number of trials
containing correct exchanges by the total number of trials.
Interobserver agreement was assessed by having a second observer
simultaneously but independently collect data with the first observer.
Percentage agreement on cigarette pica was calculated by dividing the number of
sessions during which both observers' latency measures fell within a plus or
minus 1 s window of each other by the total number of sessions in which
agreement were collected. Percentage agreement for all other responses was
calculated by dividing the number of intervals containing scoring agreements by
the total number of intervals in the session. The percentage of sessions during
which agreement was assessed for each participant ranged from 17.9% to 45.0%,
and the mean percentage agreement across participants ranged from 82.5% to
100%. Individual agreement scores are presented in Table 4.
Baseline

The participant was brought into the therapy room and sat at or stood beside
a table. There were no other materials in the room. The experimenter placed a
"cigarette" (defined as the preferred cigarette component from the previous

assessment) on the table but did not otherwise interact with the participant
during the session. Thus, the baseline sessions were similar to those of the alone
condition as described by Iwata et al. (1982/1994). An observer started a timer
when the cigarette was placed on the table and stopped the timer when cigarette
pica occurred. If cigarette pica did not occur prior to 300 s (5 min), the timer was
stopped, the cigarette was removed, and the session was terminated. Thus, the
criterion for the absence of cigarette pica was arbitrarily set at 300 s during which







28
Table 4 Interobserver Agreement





Participant Cigarette Pica Correct Exchange

% of (% Agreement) % of (% Agreement)
Sessions Sessions
Assessed Assessed

Range Mean Range Mean
Rob 33.3 -- 100 28.1 82.5- 100 93.1

Helen 44.7 85.7-100 99.7 45.0 88.4- 100 92.9

Andy 29.9 -- 100 17.9 95.0-100 95.9

Larry 35.6 -- 100 35.0 96.4-100 99.4









the response did not occur.
Noncontingent Reinforcement with Edible Item (NCR [edible item])
The effects of noncontingent reinforcement (NCR) with an edible item as a
treatment procedure was evaluated. The purpose for conducting this procedure
was to evaluate the effects of a dense schedule of free access to the preferred
edible item on cigarette pica. Data from two recent studies (Fischer, Iwata, &

Mazaleski, 1997; Lalli, Casey, & Kates, 1997) suggested that noncontingent
delivery of reinforcement (i.e., NCR) was effective in suppressing the target
behaviors even when contingent reinforcement was provided for the target
behaviors. In the Fischer et al. (1997) study, the alternative reinforcer (food) was
delivered on a fixed time (FT) 10 s schedule, while each occurrence of the target

behavior produced access to the maintaining reinforcer. Results indicated that
the target behavior decreased markedly compared to baseline, suggesting that
even if ongoing reinforcement for the target behavior was not disrupted,
noncontingent or response-independent (i.e., time-based) delivery of alternative
reinforcers at a dense schedule was effective in producing response decrement.
In the Lalli et al. (1997) study, one participant was exposed to NCR without
extinction, in which the maintaining reinforcer was delivered independent of the
occurrence of the target behavior (NCR) and contingent on each occurrence of
the target behavior (without extinction). The results showed that the target
behavior was decreased markedly compared to baseline and eventually was

eliminated during this condition. Thus, both the Fischer et al. (1997) and Lalli et
al. (1997) studies provided support that delivery of a reinforcer in an NCR
procedure may effectively compete with contingent reinforcement for the target
behavior. These results provide the basis for examining whether delivery of the

preferred edible item would effectively compete with cigarette pica when the









cigarette component was available (i.e., contingent reinforcement for the target

behavior).

Procedures for the NCR (edible item) condition were as follows. The

preferred edible item was delivered on an FT 10 s schedule for five minutes prior

to the start of the session (presession). At the end of 5 min, the session began (as

in baseline) when the experimenter placed the cigarette on the table. The FT 10 s

delivery of the edible item continued throughout the session. If pica did not

occur, the session was terminated after 300 s. If pica did occur, the session was

terminated, but the experimenter continued to deliver food for an additional 60 s.

The latter procedure avoided the possibility of inadvertently introducing a

contingency in which the edible item was no longer forthcoming following

cigarette pica. An observer started the timer as soon as the cigarette was placed

on the table and stopped it when pica occurred or was absent for 300 s. The

criterion for successful treatment was absence of pica for 300 s for 5 consecutive
sessions.

For subjects for whom a dense NCR schedule with the edible item was

effective in deterring the occurrence of pica for 300 s, a schedule thinning

procedure was implemented to examine whether leaner schedules could

maintain treatment effects produced by dense NCR schedules and, if so, may be

a practical treatment to implement under naturalistic conditions. The procedures

used were similar to those of the NCR (edible item) condition, except that

schedule thinning occurred following cigarette availability. The method of

schedule thinning was based on the mean latency to cigarette pica during

separate probe sessions. During these probes, the cigarette was not available for

five minutes while food was delivered on an FT 10 s schedule. Then, the

cigarette was placed on the table and food no longer was forthcoming. The

initial NCR schedule was set at 75% of the mean latency to cigarette pica during









the probe sessions. This schedule remained in effect for the first three sessions.
During the fourth and subsequent sessions, the NCR schedule was set at 75% of

the mean latency to responding during the previous three sessions. A restriction

was imposed while setting all NCR schedules such that the value of each

schedule would not exceed that of the previous schedule by more than 25%. This
limitation was to ensure a gradual schedule thinning process. The criterion for

successful treatment was absence of pica for 300 s for 5 consecutive sessions.
DRA plus Response Interruption

Because results of the preferred cigarette component versus preferred edible
item preference assessment suggested that food or drink items were preferred

over cigarettes, there was reason to believe that delivery of the more potent
reinforcer contingent on an alternative response may compete effectively with
cigarette pica. A response interruption procedure was added as a supplement to
the DRA procedure in order to enhance the latter's potential treatment effects.

That is, results of the cigarette versus edible item preference assessment did not

indicate exclusive preference for the alternative reinforcer, indicating that there
was a low probability that cigarette pica may occur during treatment involving

the alternative reinforcer. Thus, in order to ensure that that potential
reinforcement as result of engaging in cigarette pica would not compete with

access to the alternative reinforcer during the DRA procedure, the response
interruption procedure was added to prevent occurrence of cigarette pica. Each
session consisted of 20 training trials and a final test trial. During each training
trial, the experimenter placed the cigarette on the table, extended his or her hand,

palm facing upwards, a few inches above and to the side of the cigarette, and

instructed the participant to hand the cigarette to the experimenter in exchange
for the edible item (i.e., reinforcement was delivered for engaging in the correct

exchange, which was the alternative response). If no response occurred within









10 s, the experimenter repeated the instruction and modeled the alternative

response. If no response occurred within 10 s, the experimenter repeated the
instruction and physically prompted the participant to engage in the alternative
response. Reinforcement was only delivered when the participant engaged in

the alternative response without a physical prompt. If a cigarette pica attempt

occurred, which was defined as picking up and bringing the cigarette within 6

inches of the participant's mouth, the experimenter prevented the participant
from ingesting the cigarette by placing the experimenter's hand between the
cigarette and the mouth, and removing the cigarette from the participant's hand.

The experimenter then repeated the instruction, and physically prompted the

participant to engage in the alternative response.
The purpose of the test trial was to determine if reinforcement with an edible
item for independently turning in the cigarette (i.e., without prompting or
interrupting a pica attempt) would be effective in deterring cigarette pica.

During the test trial, the cigarette was placed on the table. No prompts were

delivered other than the experimenter extending his or her hand out to allow the

opportunity for the participant to independently engage in the alternative
response. The edible item was delivered if the alternative response occurred
independently, but pica was not prevented. The criterion for success was five

consecutive test trials in which either a correct exchange occurred in each test

trial, or the absence of cigarette pica for the 300 s prior to each test trial. The

common goal of deterring pica prior to 300 s could be achieved by fulfilling
either criterion.

Generalization

In order to determine if treatment would be effective under naturalistic

conditions, generalization of treatment effects was programmed and assessed

across two different parameters (setting and experimenter) during three phases.









In all phases, procedures similar to those just described for the DRA plus
response interruption condition were used. During Phase 1, generalization was

programmed by having a novel experimenter (T2) implement the DRA training
trials in a novel therapy room (S2) in the day treatment program. Generalization
of treatment effects was assessed during the subsequent test trial. During Phase
2, a novel experimenter (T3) implemented the same procedures outside but close
to the vicinity of the day treatment program (S3). During Phase 3, various novel
therapists implemented the procedure in a variety of settings (varied S/T), such
as outside the grounds of the participants' residences and worksites. The
criterion for completing each phase was five consecutive test trials in which
either a correct exchange occurred in each test trial, or if cigarette pica was absent
prior to 300 s in each test trial.

Additional Procedures for Larry
Results of Larry's preferred cigarette component versus preferred edible item
preference assessment showed a preference for cigarettes, suggesting that a DRA
procedure identical to that used for the other participants was unlikely to be
effective. However, it was possible that a noncontingent schedule of food
presentation (NCR [edible item]) might suppress pica by producing a general
satiation effect. Thus, Larry was exposed to a series of NCR conditions, followed
by DRA conditions in which the preferred cigarette component was altered.
Other participants were not exposed to the series of NCR and DRA conditions,
or the final procedure (satiation).

NCR. Dense schedules of NCR (FT 10 s) were used throughout this phase
with a variety of stimuli. Following the NCR (edible item) condition, the stimuli
used were herbal cigarettes and nicotine-based products, which represented
safer alternatives to pathogen-laden cigarettes. In the NCR (herbal cigarettes)
condition, the filter of each herbal cigarette was removed and the remainder









divided into 8 equal pieces (each approximately 0.7cm in length). The herbal
cigarettes, which primarily contained marshmallow and herbs (clover, rose, and
coltsfoot), were delivered on an FT 30 s schedule for 5 minutes prior to the start

of the session. During the session, an FT 30 s schedule was used instead of a
denser schedule (e.g., FT 10 s) because anecdotal observations indicated that it
took approximately 30 s for Larry to chew each herbal cigarette. The session
started when the experimenter placed a cigarette on the table. Subsequent to
cigarette availability, the schedule of delivery of herbal cigarette continued until

300 s had elapsed or until 60 s following the occurrence of cigarette pica.
Following this condition, several nicotine-based products were delivered to
determine if free access to alternative sources of nicotine could compete
effectively with cigarette pica. In other words, perhaps free access to the
maximum allowable amount of the maintaining reinforcer may be sufficient to
satiate Larry from engaging in cigarette pica to obtain additional amounts of
nicotine by eliminating the apparent establishing operation (Michael, 1982) for
cigarette pica. During the NCR (nicotine pouch) condition, one pouch [Skoal]@
was given to Larry to chew for 30 s prior to cigarette availability. No additional
nicotine pouches were given following cigarette availability. During the NCR
(nicotine gum) condition, one piece of Nicorette@ gum (2 mg) was given to Larry
30 seconds prior to cigarette availability. No additional nicotine gum was given
following cigarette availability. In a subsequent phase, a piece of nicotine gum
was provided 30 minutes prior to cigarette availability. The 30 min presession
delay was based on information provided by the manufacturer indicating that
peak levels of nicotine absorption are reached 30 min after chewing the gum.
Following cigarette availability, Nicorette@ was no longer delivered.
DRA (edible item) and spiked cigarettes. Although results of the preference
assessment showed preference for the cigarette component over the edible item,







35

results also indicated preference for the edible item over spiked cigarettes. Thus,

it was possible that the alternative response (exchanging the cigarette component
for the edible item) could be initially shaped by using spiked cigarettes and that
the response might maintain when unaltered cigarettes were later introduced.

During this phase, each cigarette was coated ("spiked") with approximately 1 ml

of Scorned Woman Hot Sauce@. Each session consisted of 20 training trials and a
subsequent test trial. During each training trial, the experimenter placed the
spiked cigarette on the table, extended his or her hand, palm facing upwards, a
few inches above and to the side of the cigarette, and instructed Larry to hand

the spiked cigarette to the experimenter in exchange for the edible item. If no

response occurred within 10 s, the experimenter repeated the instruction and
modeled the alternative response. If no response occurred within 10 s, the

experimenter repeated the instruction and physically prompted Larry to engage
in the alternative response. Reinforcement was delivered only when Larry

engaged in the alternative response without a physical prompt. There were no

consequences on pica attempts (i.e., a response interruption procedure was not

added because it was thought that DRA in combination with distasteful
cigarettes would be sufficient to deter pica). During the test trial, the spiked
cigarette was placed on the table. No prompts were delivered other than the

experimenter extending his or her hand out to allow Larry the opportunity to

engage in the alternative response. There was no consequence for pica.

Reinforcement was delivered contingent on the alternative response.
DRA + response interruption + overcorrection. Procedures used were similar
to those described in the DRA (edible item) plus spiked cigarettes condition
except that, contingent on each pica attempt: (a) the response was blocked; and

(b) an overcorrection procedure was implemented, which consisted of the









experimenter physically prompting Larry to repeatedly hand the cigarette to the

experimenter for 5 min.

DRA + response interruption + water mist. Procedures used were similar to

those during DRA + response interruption + overcorrection condition, except
that a water mist procedure was used in lieu of overcorrection. During the water
mist procedure, contingent on each occurrence of cigarette pica, the experimenter

held a plant sprayer filled with room temperature water approximately 6 inches

from Larry's face and, with the sprayer set on spray mode, sprayed Larry once.
DRA + response block + hot sauce (in mouth). The only procedural
difference between this phase and that of the DRA + response interruption +
water mist condition was that, contingent on each pica attempt, the experimenter

squirted 2 ml of Scorned Woman Hot Sauce into Larry's mouth.

Satiation. The rationale for this procedure was that ingestion of a large

number of distasteful cigarettes might deter cigarette pica. The procedure
consisted of coating 9 unsmoked cigarettes (one short of the maximum daily
intake) with Scorned Woman Hot Sauce and giving them to Larry five minutes

prior to cigarette availability. At the end of 5 min, the 10th cigarette (unaltered)

was placed on the table.














RESULTS AND DISCUSSION
Figure 1 shows the results for Rob (top panel), Helen (middle panel), and
Andy (bottom panel). Rob engaged in cigarette pica at very short latencies
during baseline (mean = 3.3 s). During NCR (edible item) at FT 10 s schedules,
Rob met the criterion for completion at the outset of treatment as pica did not

occur for 300 s for the first five sessions. During schedule thinning, the pattern of
responding was variable. There were only two sessions in which pica was absent
for 300 s (session #14, during which the NCR schedule was FT 148 s; and session
#20, during which the NCR schedule was FT 88 s), so Rob did not meet criterion
for successful completion of treatment. Two responses were measured in the

DRA plus response interruption condition: (a) correct exchanges during the
training trials; and (b) latency to cigarette pica during the test trials (a correct
exchange during a test trial was scored as absence of pica for 300 s). Rob's data
during DRA indicated that for the first 12 sessions in this phase, he inconsistently
abstained from ingesting the cigarette until reaching the 5-session criteria with
the first experimenter in the original training room. The pattern of correct
exchanges was more stable throughout, and occurred at a fairly high percentage
of trials (mean = 93.5%). During generalization, Rob's data indicated that correct
exchanges occurred during a high percentage of the training trials (mean =
98.2%), and the pattern of responding was stable throughout generalization.
His data also indicated that cigarette pica did not occur at all during any of the
test trials.
































Figure 1. Latency to cigarette pica (seconds) and percentage of trials of correct
exchange (during training trials) for Rob, Helen, and Andy.



















BL NCR DRA
FT 10s ..


20 30 40
SESSIONS


50 60 70 80


300

250

200

150

100

50

0

z
o 300

250*

. 200
U
150
Coo
LD 100
u
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200

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100

50


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SI



LU
100


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z
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20
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40

Helen also showed very short latencies to cigarette pica (mean = 6.9 s) during

baseline. During the NCR (edible item) condition, when the schedule was FT 10

s, latencies to responding generally were rather short (mean = 40.6 s). Although

the latencies increased somewhat, pica was absent for only one session; thus,

Helen failed to meet criterion for completion of treatment. Consequently,

schedule thinning was not implemented. There was no reason to believe that
lean schedules of NCR would be effective in deterring pica if a dense schedule

failed to compete with the behavior. During DRA + response interruption,

Helen took the minimum number of sessions to meet criterion for successful

completion of treatment (i.e., cigarette pica never occurred for 300 s in each of the
first five sessions). She engaged in correct exchanges during 100% of the training
trials. During generalization, the same pattern of responding occurred in that

she met criterion for successful completion of each phase of generalization with

the minimum number of sessions, and engaged in correct exchange 100% in all

but one session (91%) (mean = 99.4%).

Andy showed short latencies to pica during baseline (mean = 4.3 s). During

NCR (edible item) at an FT 10 s schedule, the pattern of responding was

extremely variable (sessions #16 #26) before criterion for treatment completion

was met during the subsequent five sessions. During schedule thinning, the

pattern of responding once again became variable. There were only three
sessions in which pica was absent for 300 s (session #36, NCR schedule = FT 18 s;

session #37, NCR schedule = FT 22 s; and session #42, NCR schedule = FT 21 s),
so he also did not meet criterion for completion of treatment. During DRA +

response interruption, his data showed that the percentage of trials with correct

exchange during the first two sessions was relatively low compared to those of

the next five sessions; furthermore, cigarette pica occurred prior to 300 s in the
first two trials but was absent in the subsequent five trials. During







41

generalization, the pattern of correct exchanges was variable but the overall level

was fairly high (mean = 86.6%). His data also indicated that cigarette pica was

absent for 300 s during the test trials for the first two phases (S2T2 and S3T3) of
generalization. However, during the varied S/T phase, pica occurred before 300

s during sessions 67 through 69. Nevertheless, Andy met criterion for successful

completion of generalization as pica was absent for five consecutive test trials

during the final five sessions of the varied S/T phase.
Figure 2 shows the results of treatment for Larry. During baseline, Larry's

pica occurred at relatively short latencies (mean = 10 s). During the NCR (edible

item) condition, the pattern of responding was a little more variable than it was

during baseline, but his mean latency to pica only reached 18.5 s. Similar results
were obtained for the remaining NCR conditions. The mean latencies to pica

during the various NCR conditions were as follows: 16.6 s (herbal cigarettes), 4.5
s (nicotine pouch), 34.6 s (nicotine gum), and 5.8 s (nicotine gum, 30 min delay),
indicating that NCR with a variety of alternative stimuli, including nicotine-

based products, did not deter pica.

During the DRA + distasteful substance procedure, although an increasing

trend in correct exchange was seen towards the middle half of the phase, a

similar trend was not observed for latency to cigarette pica. Additionally,

cigarette pica was absent in only 1 of 42 sessions and the mean latency to the

behavior was 20.3 s. Hence, the results indicated that DRA with spiked

cigarettes was ineffective. The mean latencies to pica during the final three DRA
procedures were as follows: 5.1 s (DRA + response interruption +
overcorrection), 3.6s (DRA + response interruption + water mist), and 3.2 s (DRA

+ response interruption + distasteful substance squirted into the mouth). The

mean latency to cigarette pica during the satiation procedure was 3.2 s. The mean































Figure 2. Latency to cigarette pica (seconds) and percentage of trials of correct
exchange (during training trials) for Larry.































NCR

* Cigarette Pica
o Correct Independent
Exchange


Satiation
100 <
-)
6U
tu

80
z


60 t





0
z




u
20 cU
J
0


- 300-
O0

. 250-

U

S -
zoo-


150-


o ioo-
O 100"
--

50-
z


10 20 30 40 50 60 70 80 90 100 110 120


SESSIONS







44

latencies during the last four phases of treatment were shorter than that of
baseline, indicating that those procedures were ineffective.
Thus, in summary, the data showed that NCR (edible item) at a dense
schedule was an effective procedure for Rob and Andy; however, thinning the
schedule of NCR did not maintain initial treatment effects. The implication of
these results is that a practical NCR procedure (i.e., one designed to be
implemented under naturalistic conditions) was not feasible. On the other hand,
DRA proved to be effective for Rob, Helen, and Andy; furthermore, treatment
effects were obtained quickly for Helen and Andy. Results of the generalization
phase showed that treatment effects successfully generalized across multiple
experimenters and multiple settings for Rob, Helen, and Andy. Finally, staff
were trained to implement the DRA procedure.

By contrast, none of the 10 treatment procedures was successful in reducing
Larry's cigarette pica. Although more intrusive forms of punishment than those
used in the study may have been more effective, these procedures were not
evaluated because the severity of the behavior problem did not seem to warrant
such interventions. Therefore, Larry was regarded as a treatment failure, and
further attempts to eliminate pica using contingencies of reinforcement and
punishment were abandoned. Instead, supervision procedures were
implemented to minimize occurrences of cigarette pica. Briefly, these procedures

consisted of having staff continually keep Larry within view and in close

proximity such that pica attempts could be blocked, and having staff frequently
clean the area surrounding Larry for cigarette products.














GENERAL DISCUSSION

The purpose of this study was to evaluate a systematic methodology for the

assessment and treatment of cigarette pica, a topic that has received scant

attention in the applied literature. The methodology consisted of a series of

stimulus preference assessments, interventions based on the outcome of those

assessments, and generalization of treatment effects. The preference assessments

identified the preferred cigarette component, competing reinforcers, and

effective assessment-based treatments for three of four participants.

A noteworthy feature missing from the study was an attempt to rule out the

role of social consequences as possible maintaining reinforcers. A pretreatment

functional analysis was not conducted because there were no data suggesting

that cigarette pica was maintained by social reinforcement. Additionally, all

participants were observed to engage in pica when alone, suggesting that the

behavior was maintained by automatic reinforcement. Thus, the approach taken

was to assess cigarette components that were preferred, as well as alternative

reinforcers that might effectively compete with pica. However, it is remotely

possible that cigarette pica might be maintained by social reinforcement, and

additional research is needed to determine the extent to which this is observed.

One way to gather evidence for or against the contribution of social

consequences would be to simply conduct a functional analysis of cigarette pica

similar to that used by Piazza et al. (1996).

Several limitations, in addition to the absence of a general functional analysis
of cigarette pica, should also be noted. First, one of the interventions (NCR) was

not a practical treatment procedure and, as a result, the range of effective

45









procedures that can be used to eliminate cigarette pica was limited. In other
words, the data indicated that infrequent delivery of small amounts edible items
would not be effective under experimental conditions, thus there was reason to
believe that treatment also would not be effective under naturalistic conditions.

Second, although DRA was effective, the alternative response (exchanging
cigarettes for the alternative reinforcer) shares some topographical features with
the target response (cigarette pica). Thus, the initial part of the behavioral chain
leading to pica was maintained, and in the absence of consistent reinforcement
by experimenters, pica may be more likely to recur. Third, extensive attempts to
develop a treatment program, including the use of nicotine-based reinforcers and
the use of punishment contingencies produced no suppression of Larry's pica.
There are several noteworthy features of the study. First, the dependent
variable measured was actual cigarette pica, which was identical to that
measured in the Foxx and Martin (1975), Matson et al. (1978) and Piazza et al.
(1996) studies but contrasts with that measured in the Donnelly and Olczak
(1990) study. Second, measures were taken to minimize health risks associated
with ingestion of cigarettes. This was conducted by limiting the number of
cigarettes ingested per day, using latency to provide a sensitive measure of pica
given that the frequency of cigarette ingestion was limited, and using syringes to

manufacture cigarette butts that were relatively free of saliva-borne and
incidental pathogens. The use of a latency measure and the manufacturing
process both are novel to the assessment and treatment of cigarette pica. Third,
the assessment procedures were useful in identifying the preferred component of
the cigarette responsible for cigarette pica, as well as indicating preference for

preferred edible items over preferred cigarettes. In essence, the results of the
stimulus preference assessments provided the basis for developing the NCR and
DRA interventions. More generally, the cigarette component preference









assessment used in the present experiment and in the Piazza et al. (1996) study

involved a direct modification of stimulus characteristics of pica objects. Such a
methodology has not been conducted in previous research on pica and also
represents an extension of the indirect methodology proposed by Favell et al.
(1982) and Mace & Knight (1986) in their attempts to identify the behavior's
maintaining reinforcer. Finally, a systematic implementation of the DRA
procedure across multiple experimental settings provided a means of
generalizing treatment effects.
One avenue for future research would be to identify other components of a
cigarette that make its ingestion reinforcing. The methodology used to identify
the preferred cigarette component yielded three distinct stimulus characteristics
of the cigarette and preference was identified for two of those features
(unsmoked cigarettes and cigarette butts). However, it is likely that additional
stimulus features of the cigarette may be responsible for cigarette pica that were
not identified in the experiment. Specifically, unsmoked filters, unsmoked
cigarettes, and cigarette butts differ along several dimensions such as taste,

texture, presence or absence of nicotine, shape, and size to name a few. Of these
possible stimulus characteristics, taste and nicotine appear to be the more likely
relevant maintaining reinforcers as they are unique to cigarettes. In order to
determine if taste is the relevant stimulus characteristic, one would simply have
to conduct a preference assessment between two stimuli: the preferred cigarette

component, and the preferred cigarette component with modifications made
only to the taste feature of that cigarette component. Preference for the preferred
cigarette component would suggest that taste may be the relevant stimulus
characteristic maintaining cigarette pica. It would be difficult to determine if
nicotine, which is present in both unsmoked cigarettes and cigarette butts,

maintained cigarette pica. The most direct method to investigate this hypothesis









would be to conduct a preference assessment between the preferred cigarette

component and a similar cigarette component devoid of nicotine. Preference for

the cigarette component would implicate nicotine as the maintaining reinforcer.

However, at the present time, nicotine-free tobacco cigarettes are not yet
available (Piazza et al., 1996).
A second avenue for future research would be to examine further

manipulations with NCR in an attempt to identify conditions under which it may

be effective in eliminating pica. It may be the case that a longer duration of

noncontingent access to edible items at a dense schedule may prove effective in

deterring pica. In other words, perhaps the 5 min presession NCR procedure
with edible items was insufficient to remove the behavior's establishing
operation such that the participant would still be motivated to engage in
cigarette pica. There is some evidence suggesting that providing an

overabundance of reinforcers (i.e., reinforcer satiation procedures) at a level far

exceeding baseline levels can produce rapid elimination of the target behavior.
For example, Rast, Johnston, Drum, and Conrin (1981) found that providing food
that exceeded the baseline breakfast quantity by 5-8 times and the baseline lunch

quantity by 3-6 times eliminated rumination; however, delivery of food quantity

twice that of baseline levels produced no effect. Thus, one way to examine the

effects of reinforcer satiation on cigarette pica would be to allow the participant
free access to edible items until consumption ceased for some time period,

suggesting that satiation was achieved. Subsequently, a cigarette would then be

made available and the absence of pica would suggest treatment effectiveness.

A third avenue for future research would be to examine the basis of treatment

failure in Larry's case in an attempt to arrive at an effective intervention for his
cigarette pica. Based on results of the preferred cigarette component versus
preferred edible item preference assessment, altering the stimulus characteristics









of the cigarette to shift preference in favor of food did not yield an effective
intervention. That is, although there was some degree of preference for the
edible item over the spiked cigarette, a DRA procedure involving exchanging the
spiked cigarette for the edible item was ineffective. This may suggest that the
consequence of the distasteful cigarettes likely were insufficient to override the

reinforcing effects produced by cigarette pica. If so, other means of altering the
stimulus characteristics of the cigarette may be needed to produce aversive
consequences sufficient to override the reinforcing consequences of cigarette
pica. Specifically, it may be possible to add chemicals to the cigarette such that

ingestion of a small amount may be sufficient to produce acute adverse
physiological reactions (i.e., vomiting) without causing physical harm but
sufficient to suppress cigarette pica. However, the rationale for conducting such
an intrusive procedure should first involve an evaluation of the severity of
cigarette pica. If the potential for physical harm is great should cigarette pica

remain untreated, and if punishment procedures pose no risk of physical harm,
then perhaps the use of more intrusive interventions similar to that just
described may be used.
Whereas other topographies of SIB have been the subject of extensive inquiry,
research on the assessment and treatment of cigarette pica appears to be in its

developmental stages. This study has illustrated a methodology highlighting the
vital role of assessment in the treatment of cigarette pica, as well as the
importance of evaluating generality of treatment effects. Undoubtedly, several
limitations of the study are noted and may well serve as areas for future
research. Thus, applied researchers should continue to refine the methodology

described in the study to gain a more thorough understanding of etiological

factors of cigarette pica such that the behavior can be rapidly, consistently, and
effectively eliminated.














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BIOGRAPHICAL SKETCH


Han-Leong Goh graduated from the University of Pennsylvania with a B.A.

in psychology in May 1990. Mr. Goh was first exposed to behavior analysis

while working as a clinical specialist at the Children's Seashore House in

Philadelphia. As a direct consequence of his work experience, he enrolled at the

University of Florida in the Fall of 1992 to work with Dr. Brian Iwata in order

that he may further his professional career in applied behavior analysis. For the

past five years, he has been working as a graduate research assistant at the

Florida Center on Self-Injury under the supervision of Dr. Iwata where Mr. Goh

was involved in research projects on the assessment and treatment of self-

injurious behavior (SIB). Mr. Goh is expected to receive his Ph.D. in Fall of 1997

and is about to commence employment as a postdoctoral fellow at the Kennedy

Krieger Institute of the Johns Hopkins University School of Medicine, where he

will continue research in the assessment and treatment of severe behavior

disorders.














I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope
and quality, as a dissertation for the degree of Doctor of Philosophy.




Brian A. Iwata, Chairman
Professor of Psychology


I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope
and quality, as a dissertation for the degree of Doctor of Philosophy.




Marc N. Branch, Cochairman
Professor of Psychology



I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope
and quality, as a dissertation for the degree of Doctor of Philosophy.









I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope
and quality, as a dissertation for the degree of Doctor of Philosophy.




Alan C. Spector
Associate Professor of Psychology



I certify that I have read this study and that in my opinion it conforms to
acceptable standards of scholarly presentation and is fully adequate, in scope
and quality, as a dissertation for the degree of Doctor of Philosophy.




Stephen M. Golant
Professor of Geography



This dissertation was submitted to the Graduate Faculty of the Department
of Psychology in the College of Liberal Arts and Sciences and to the Graduate
School and was accepted as partial fulfillment of the requirements for the
degree of Doctor of Philosophy.



December 1997


Dean, Graduate School






















17





















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